INITIAL COMMENTS
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This is a report of the on-site licensure renewal inspection conducted on March 12 through 13, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on April 9, 2007.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Feedback was not documented on outside training in all employee records reviewed.
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Plan of Correction
Human Resources sent notice via email to all Program Directors and Supervisors in early March 2007, informing of the regulation/policy requiring the collection of feedback on all completed trainings. The HR Department is ensuring compliance with this standard by monitoring all submitted training certificates, and not issuing credit for the training until the evaluation is completed and submitted to Human Resources. HR Director is responsible for the overall organizational compliance with this standard. Target date for completion was March 15, 2007. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
A fire drill was not documented for December 2006.
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Plan of Correction
Maintenance Supervisor or other Maintenance Department personnel will conduct monthly unannounced fire drills with complete and accurate documentation. Program Director will ensure compliance with this standard through quarterly evaluation of the Fire Drill logs. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The fire drill log for January through July does not state whether or not the fire alarm or smoke detector was operable or not.
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Plan of Correction
Program Director will ensure Maintenance Supervisor will conduct monthly fire drills with complete and accurate documentation including the date, time, the amount of time taken to evacuate, exit routes used, number of persons in the building, problems encountered, and whether fire alarms/smoke detectors are operative. The fire drill documentation form has been revised by Maintenance Supervisor to include all pertinent information as stated above. |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
The policy and procedure manual at the main administrative office and the manuals at the facilities were not consistent with regard to policies and procedures. The organization of the manual made the review difficult and increased the potential for misunderstanding the intent of various procedures.
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Plan of Correction
The Master Policy Manual will be reviewed by Policy Coordinator, and the Chief Operating Officers from each division (Adult Residential, Adolescent Residential and Outpatient). The purpose of this review is to 1) ensure consistency of policies across the organization, and 2) to re-organize the Master manual, separating out Drug and Alcohol Program policies from DPW-licensed Program policies, ensuring ease of access to the policies, and diminishing the potential for misunderstanding of the intent of the policies/procedures. The Policy Coordinator will be responsible for ensuring that the Table of Contents accurately reflect the content of the manual. The CEO/Project Director, will be responsible for ensuring timely completion of this project. Target date for final completion of this project is June 1, 2007. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
The HIPAA Notice of Privacy Practices form contains incorrect information in sections III L. and O.; IV. F; V. A and C.; VI E and H and VII. This form was found in 4 of 4 client records.
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Plan of Correction
The Notices of Privacy Practices document was revised on April 4, 2007 by the Medical Records Corporate Coordinator, as recommended by Department of Health staff during the licensing visit. The COO - Adult Residential Services, will submit the revised document to the Department of Health for review and approval by April 13, 2007. Once approved by the State, targeted implementation is April 20, 2007. |
709.53(a)(5) LICENSURE Progress Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Progress notes.
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Observations
Progress notes did not address treatment plan goals, which is to be done per Pyramid policy.
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Plan of Correction
The Program Director, will conduct individual clinical supervision with current counselors regarding appropriate documentation of client progress in the record. Supervision will focus on the quality of the documentation of the data, assessment, and plans relative to treatment. Counselors will receive orientation and training regarding the same. The Program Director will ensure compliance with this standard through ongoing clinical supervision and monthly chart monitors. |